Armadillos Transmit Leprosy to Humans

Command the children of Israel that they put out of the camp every leper, and every one that hath an issue, and whosoever is unclean by a dead armadillo.
— A horrible misquote of Numbers 5:2

Leprosy, now also called Hansen’s disease, is caused by the bacterium Mycobacterium leprae, a cousin of the bacterium that causes tuberculosis. Leprosy causes a rash and nerve damage that causes skin numbness. Before the age of antibiotics patients were isolated in “leper colonies”. Now the disease is curable.

Before this week all transmission of Hansen’s disease was thought to be from person to person. Armadillos have long been known to carry M leprae also, but it was thought that armadillos and humans had different strains of the bacteria and could not spread leprosy to each other.

A very clever study in this week’s New England Journal of Medicine strongly suggests that humans in the US South are contracting leprosy from armadillos. The study sequenced the DNA of M leprae from a number of patients and armadillos. Patients who likely contracted leprosy abroad, in countries where it has a higher prevalence, had bacteria with strains common in their country of origin. However, patients without foreign travel had a unique M. leprae strain that has not been found elsewhere in the world. This same strain was found in the local armadillos.

This week’s New England Journal of Medicine also has an impressive picture of a rash due to leprosy. (See the link below if interesting rashes float your boat.)

Very few people in the US have leprosy, fewer than four thousand. And you can’t get it by being in the same room as an armadillo. You probably have to be exposed to an armadillo’s blood or eat the uncooked meat. And, again, leprosy is completely treatable. So an encounter with an armadillo is much safer than, say, a bear.

Nevertheless, the media flocked to this story (links to articles below), since who doesn’t want an excuse to publish a picture of a cute armadillo?

So if you accidentally drive over an armadillo, or if you hunt armadillo, don’t handle the carcass without gloves. And if you eat armadillo meat make sure it’s fully cooked. Though I think leprosy or no leprosy, anyone who eats armadillo should be taken out of the camp.

Learn more:

Wall Street Journal article: Leprosy Linked to Armadillos

LA Times article: Armadillos pass leprosy to humans, study finds

New England Journal of Medicine images in clinical medicine: Tuberculoid Leprosy

New England Journal of Medicine article: Probable Zoonotic Leprosy in the Southern United States

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More Than Half of Americans Take Dietary Supplements

Did you know that the Centers for Disease Control has something called the National Nutrition Monitoring System? And apparently it’s a good thing too, since who else would monitor the nation’s nutrition?

This week the intrepid bunch at the National Nutrition Monitoring System released a report detailing how many of us use dietary supplements and which ones we use. (The link to the report is below, but be warned. It’s not scintillating.) The report’s major finding is that for the first time over half of US adults are now using nutritional supplements. Since nutritional supplements are a bazillion dollar industry, this generated much press coverage (some of which I link to below).

There is some good news and some bad news lurking in the report. The good news is that more people may be taking supplements that are actually helpful. For example, the number of people taking calcium supplements and vitamin D supplements is increasing, and there is evidence that some people benefit from these supplements.

Folic acid is critical in women of child-bearing age to prevent birth defects, but the use of folic acid has not changed.

(If you’re wondering whether you should be taking calcium or vitamin D or folic acid, see the links to my reviews below.)

The bad news is that the most common supplement taken by Americans is a multivitamin, which is defined to mean a supplement with at least three components. Virtually no one benefits from multivitamins in North America. The indigent in the US are overwhelmingly overweight, not vitamin deficient. And a person with a reasonable diet is getting all the vitamins and minerals she needs in her food.

So the increasing rate of use of multivitamins will occur without any increase in any marker of health. If you should be taking a specific vitamin or mineral for a specific indication, take it. But it’s safe to skip the multivitamins. If we all stopped, I’m confident the resourceful staff at the National Nutrition Monitoring System could find something else to count.

Learn more:

LA Times Booster Shots: Vitamin supplements are on the rise as most adults take them now

NPR Health Blog article: More Than Half Of Americans Take Dietary Supplements

Centers for Disease Control report: Dietary Supplement Use Among U.S. Adults Has Increased Since NHANES III (1988–1994)

My reviews of some supplements:

Rethinking Calcium Supplements

The Most Recent Celebrity Vitamin: D

Folic Acid: Fabulous for Fertile Females, Feckless for Fellows

Tangential Miscellany

Posting will be on hiatus next week and will resume in two weeks. I wish all my readers a happy Easter and happy Passover.

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New Study on Estrogen Yields Confusion but Same Recommendations

This week a study published in the Journal of the American Medical Association revealed new results about estrogen use and generated major media hubbub. (See the links below for some of the media coverage, the article and an accompanying editorial.) To understand the kerfuffle it helps to review how our understanding of estrogen replacement therapy has evolved.

A generation ago, based largely on intuition and on epidemiologic studies, we were convinced that long term estrogen replacement therapy was beneficial for women’s health. The theory made a lot of sense: Women before menopause have fewer heart attacks then men, but their risk of heart attack increases after menopause. Well, that’s just when their ovaries stop making estrogen, so estrogen must be protective. Like most untested things that make perfect sense, this was false.

But before we get too far ahead, we have to understand progesterone. Estrogen taken for a prolonged duration stimulates the lining of the uterus and increases the likelihood of uterine cancer. Estrogen taken with progesterone doesn’t have that risk. So for women who still have a uterus hormone replacement therapy (HRT) has come to mean combination therapy with estrogen and progesterone.

So finally in 1991, a randomized trial was done to test what everyone already thought they knew – the Women’s Health Initiative (WHI). Women were randomized to combination HRT and placebo. The results were that women on HRT had more strokes and at least as many heart attacks as the placebo group. There was much wailing and gnashing of teeth, from some doctors because they refused to believe it, from others because we realized that we had been harming countless women for a generation based on shoddy science.

Since WHI our understanding of the benefits and risks of HRT has been the following.

  • HRT increases the risk of stroke
  • HRT does not prevent heart attacks
  • HRT effectively treats osteoporosis and prevents fractures
  • HRT increases the risk of breast cancer
  • HRT effectively treats the symptoms of menopause

Since there are far safer treatments for osteoporosis (the family of medicines called bisphosphonates), the evidence-based recommendation has been that HRT is only indicated for women who suffer from intolerable menopausal symptoms and should only be used in the lowest dose and the shortest duration possible. The goal of HRT is symptom relief and not any long-term health benefit.

After the WHI findings HRT use declined dramatically, though some physicians and researchers would not give up their infatuation with estrogen. They argued that it was the progesterone that was causing all the risks in HRT, and that estrogen alone would be safer.

Now remember that estrogen without progesterone increases the risk of uterine cancer, so it can only be given safely to women who have had a hysterectomy. A branch of the WHI randomized over 10,000 women with prior hysterectomy to estrogen alone or to placebo. This trial was stopped early because of the increased frequency of stroke in the estrogen group. (See link below to my post about this finding back in 2006.) This should have been the final nail in the coffin of HRT.

This week’s study adds very little to our knowledge. It followed the women in the estrogen-only trial for 10 years after the completion of the trial, meaning for 10 years after they stopped taking estrogen or placebo. The increased risk of stroke went away after the women stopped estrogen, but so did the decreased risk of fractures. Some small health benefits were found in younger women (in their 50s) taking estrogen, but far too much has been made of that since to achieve this small benefit the women first had to be exposed to an increased risk of stroke.

This week’s revelation does not change the indication for HRT in any way. It should simply make women in their 50s less anxious about the long-term dangers of short-term HRT taken only for symptom relief.

Learn more:

New York Times article: Estrogen Lowers Breast Cancer and Heart Attack Risk in Some

Wall Street Journal article: Estrogen’s Effects Tied to Age

My last review of the evidence on estrogen in 2006: The Evidence for Estrogen Hormone Treatment Gets Worse

Journal of the American Medical Association editorial: Short-term Use of Unopposed Estrogen

Journal of the American Medical Association article: Health Outcomes After Stopping Conjugated Equine Estrogens Among Postmenopausal Women With Prior Hysterectomy

Tangential Miscellany

If you’re reading this in an email, I hope you like the new look of the email manager I’m using. Please also check out my revamped website which lets you sign up for the weekly email (if you’re not already getting it) and lets you connect with me on Twitter and Facebook.

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Eat Right for Your Belt Size, Not Your Blood Type

Every couple of months I get asked this same question.

“Doc, what’s my blood type?”

I load my “why you don’t need to know your blood type” speech from my cerebrum and press replay, trying to add a little spontaneous variation for authenticity.

“Actually, I’ve never checked it.”

“I thought you check everything.”

“Nobody checks everything. There are thousands of different available blood tests. Most of them would be completely useless to you.”

“Well doc, could you check my blood type?”

“I’m happy to, but unless a surgeon asked you to have it checked in anticipation of a surgery, it’s really not a handy thing to know.”

“Really? What if I get hit by a truck and need a transfusion?”

“If you ever need a transfusion and tell them your blood type, they won’t believe you. They’ll check it again.”

“But I need to know it because I heard about this great diet…”

Oh, no! Another trusting soul nearly lost in the sticky swamp of quackery. In 1996 a naturopathic doctor published “Eat Right 4 Your Type” a book claiming that your blood type determines your ideal diet. If you want the physiologic details of why this connection between diet and blood type is complete nonsense, check out the links below, especially the detailed and scathing book review from Quackwatch. (By the way, Quackwatch is a terrific resource for sorting the scams from the truth in medicine.)

But forget the physiology. This link between optimal diet and blood type would be very easy to prove without knowing any physiology. You would just take a large group of overweight adults, check their blood types and randomize them into two groups. Group 1 would be assigned the diet appropriate for their blood type according to the book. Group 2 would be assigned a diet suggested by the book for some other blood type. If group 1 lost significantly more weight than group 2 you would have convincing proof that the book isn’t a pile of rubbish. That trial has never been done, though the book has been republished several times. So it makes claims that make no physiologic sense and are unproven.

So why do people fall for it? Because the diets suggested for each blood type are fairly reasonable. Any one of the four diets is fairly healthy and could lead to weight loss, but you can pick one of the four at random; they have nothing to do with blood type. So (just like with bogus cold remedies) people try it, get good results, and spread the word.

“Well, thanks, doc! Sounds like I should just eat less and maybe crank up the exercise a couple of notches.”

“You’re very welcome. By the way, there is a beautiful way to find out your blood type and save a life – donate blood.”

Thus, quackery is foiled again, and there is much rejoicing!

Learn more:

Quackwatch book review: Eat Right 4 Your Type

Wikipedia article: Blood type diet

WebMD article: The Eat Right for Your Blood Type Diet

The Cedars-Sinai blood donor facility

Public Service Announcement: Starve a Vampire, Donate Blood

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A Pulmonologist Defends Benzonatate

Last month I posted about benzonatate, a cough suppressant also marketed under the brand Tessalon. (See the link below for the original post.) In that post I detailed an FDA warning about the serious potential side effects of benzonatate, especially in accidental overdoses in children. I also passed along the conclusion of the Medical Letter that safer cough suppressants were available.

My colleague Dr. Roy Artal, a pulmonologist, wrote to me a very thoughtful defense of benzonatate, which he let me share with you.

The thrust of the advisory is that the medication bears a potential resemblance to a candy drop, and that patients need to be cautioned to keep the medication in child resistant containers, etc. In terms of the medication’s safety profile, the FDA article indicates that in the period 1958 through 2010 only 31 cases of benzonatate overdose were reported to the FDA.

As a pulmonologist, chronic cough is one of the most common indications for an office visit with me, and in that setting I’ve found benzonatate to be very well tolerated, effective, and to have an excellent side effect profile. I have had a handful of patients (<2%) come back and tell me it made them slightly woozy, and those patients have simply exercised common sense and discontinued the medication on their own.

I have no qualms about continuing to prescribe benzonatate, although the advisory likely will prompt me to reinforce to my patients who may have small children around the house to exercise appropriate precautions. I would also point out that this is no different from any of thousands of other medications that might be potentially toxic to a small child.

Learn more:

My original post about benzonatate: Benzonatate: A Cough Suppressant So Dangerous, You’d Rather Just Cough

Tangential Miscellany

About a month ago, the Daily Journal had a front page article about the growing popularity of direct primary care practices, practices in which physicians are paid directly by patients – New Direct Primary Care Plans Bypass Insurers and Regulators. The article describes why I and other doctors moved to a direct practice, and features a snazzy photo of yours truly. This practice model has been tagged with several different names: concierge medicine, boutique practice, direct primary care, retainer-based care. I don’t think any of the names have stuck yet, and I suspect that patients will pick the name that persists. I’d love to hear from you what name you think is best. What should I call what I do?

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News Nincompoops Narrate Nuclear Nonsense

Images from Japan continue to sadden and shock us. Over 12,000 are confirmed dead or missing due to the earthquake and tsunami, and that number will likely rise. Hundreds of thousands have been displaced from their homes. I’m having a hard time finding recent numbers on those without water and electricity, but all the stories state that this continues to be a major problem. The magnitude of what has already been lost, not to mention the serious challenges that remain to get food and water to everyone, seems overwhelming.

As if that wasn’t bad enough, some media outlets, not content with honestly reporting a cataclysmic disaster, have irresponsibly panicked and misled their viewers.

I want to be very clear about this next part. No matter what happens to the reactors in Fukushima, radiation from those reactors cannot harm people on the US West Coast.

The reason for this is simple; the effects of radiation (and of everything else) on the human body depend completely on the dose. Nothing terrible happens to us when we get a chest X-ray. In fact a chest X-ray gives us the same amount of radiation that we get from the normal environment in 10 days. If we were to receive the radiation from 500 chest X-rays at the same time we would be nauseated and fatigued and would lose our hair. The radiation from ten thousand simultaneous chest X-rays would cause bleeding. Forty thousand would cause death.

Chernobyl, the worst nuclear reactor accident ever, caused health problems only to people living in the vicinity of the reactor. Three Mile Island, the worst reactor accident in the US, caused no detectable health problems. The difference was the dose. Much more radiation was released in Chernobyl. (See link below for a fascinating NPR story on the long term effects of radiation around Chernobyl.)

The Fukushima reactors won’t release as much radiation as Chernobyl. The reactor design is much more modern, and we know much more now than they did then about how to prevent and manage meltdowns. Even in the very worst case, radiation would only harm those who are close enough to absorb a significant dose. Tokyo, about 150 miles away, is perfectly safe.

So the US West Coast is really not in any danger. That’s because the Fukushima reactors are on the other side of the Pacific Ocean, and the Pacific Ocean is what scientists call very very big.

Several concerned patients have asked me about potassium iodide tablets. You don’t need them. If you’ve already bought them, don’t take them. The LA Dept. of Health released a very helpful advisory (link below). Please take a few minutes to read it. It details the many reasons that potassium iodide would not be helpful and might be harmful. It also has excellent common-sense advice about what to assemble in your emergency kit.

The fact that California pharmacies have experienced a run on potassium iodide is a shameful testament to our scientific illiteracy and to our sensationalistic broadcast media. If we panic when there is no danger, how will we handle an actual emergency? Will we be able to display the stoic resolve that the Japanese have shown?

The worst aspect of the focus on Fukushima is that it distracts us from two much bigger stories. The first is that hundreds of thousands in Japan need help. See the link below to the American Red Cross and please consider donating. The second story is that we will eventually have a large earthquake here, and we’re not ready.

Learn more:

County of Los Angeles Department of Public Health Advisory: LA County residents cautioned to AVOID ingesting potassium iodide (with thanks to my colleagues Dr. Noam Drazin and Dr. Gene Liu for the link)

NPR story: Chernobyl’s Hot Zone Holds Some Surprises

Donate to assist victims of the Japan earthquake and tsunami through the American Red Cross

Correction:

In last week’s post I wrote “I can’t remember the last time that a natural disaster caused hundreds of deaths in an advanced country.” Of course, that’s boneheaded. My friend Bob C. reminded me that in 2005 Hurricane Katrina killed over 1,800 people in the US. I appreciate the correction.

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Disaster Preparedness

I was going to post about a different topic today, but I could not ignore the devastation that befell Japan. The powerful earthquake and subsequent tsunami have caused destruction that is difficult to grasp. (See links below for two news articles.) The magnitude of the disaster is even more sobering when you realize that Japan is a developed modern high-tech country. Japan is extremely aware of earthquake risks and has modern building codes and frequent earthquake drills. Despite these efforts in the last 24 hours hundreds have been killed, 4 million people are without electricity, and mobile phone service and public transportation have been disrupted. I can’t remember the last time that a natural disaster caused hundreds of deaths in an advanced country.

My regular readers know that I’m not one to panic. A flip through the archives will demonstrate that I’m rarely worried about whatever issue is causing the latest hand-wringing. I didn’t think H1N1 flu would hurt a lot of people. I’m not worried about irradiated food, pesticides, or plastic bottles.

But natural disasters deserve our attention. Not because an earthquake of similar magnitude might happen here, but because an earthquake of similar magnitude will happen here. It’s only a matter of time. We, like Japan, live on a fault line. An 8.9 magnitude earthquake in LA is likely to kill more than all the people who have ever died of pesticides in food and chemicals seeping from plastic bottles. Worse than the immediate destruction, such a disaster would completely overtax our emergency response systems. Paramedics, police, fire fighters, and emergency rooms would immediately have too few resources to respond to too many emergencies.

Put simply, you and your family for at least a few days would be on your own. This deserves some panic, but panic after the disaster will not be very helpful. In this case panic before the disaster is essential. Another name for that is preparedness.

The CDC (link below) has a very sensible list of suggestions for preparing for a disaster. It suggests tips for storing non-perishable food and fresh water, assembling a kit of emergency supplies, and making an emergency plan with your family.

So please take a look at the CDC recommendations and schedule a specific time to get prepared. And spare a kind thought for the wounded, the missing, the homeless and the bereaved in Japan.

Learn more:

Wall Street Journal article: Magnitude-8.9 Quake, Tsunami Strike Japan

Los Angeles times article: Japan earthquake, tsunami kill hundreds, cause crippling damage

CDC Emergency Preparedness and Response: Emergency Preparedness and You

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News Flash: Diabetes is Not Good

Type 2 diabetes mellitus has long been known to increase the risk of stroke, heart attack, kidney disease, and eye disease. In the US diabetes is the leading cause of kidney failure requiring dialysis and one of the leading causes of blindness. Diabetes is also increasing in prevalence as people become more overweight.

A study in this week’s New England Journal of Medicine attempted to quantify the risk of premature death associated with diabetes. The results were dramatic, and attracted much media coverage. (See links to articles below.)

The study was a compilation of data from 97 previous studies that were done for entirely different reasons. The studies followed over 800,000 people for an average of 13.5 years. At the time of enrollment 6% of the people had diabetes. The study simply compared the death rates of those who had diabetes at the start of the study with the rest of the subjects. The results were adjusted for age, sex, smoking status and body mass index (BMI).

The subjects with diabetes did much worse. As expected, they were more likely to die of strokes, heart attacks and kidney disease, but they were also more likely to die of liver disease, cancer, infectious disease and even suicide. On average, a 50-year old with diabetes at the start of the study died 6 years earlier than a person without diabetes of the same age, sex, smoking status and BMI.

Well, that’s pretty bad, but not as bad as what the media makes of it. This is not a randomized study. All we’ve learned is that one group dies earlier of a lot of diseases and also has diabetes, and another group dies later and doesn’t have diabetes. That doesn’t mean that diabetes causes the earlier deaths, simply that it is associated with earlier deaths. Lots of factors not measured in the study could have both predisposed to diabetes and caused other life-threatening diseases – family history, diet, different levels of exercise, or a tendency to eat ice cream while driving on the freeway. It doesn’t tell us about diabetes as much as it tells us about the people who happen to have it. So the LA Times headline “Diabetes can take six years off your life…” is completely misleading.

Does this help doctors or patients diagnose or treat diabetes? No. Does it mean that the day a patient is diagnosed with diabetes the date of her death advances 6 years sooner? Not at all. This may provide guidance for scientists designing studies to better clarify the harms caused by diabetes, but for doctors and patients there is no actionable information here. It’s just a reminder that if someone comes to your door offering you diabetes, you should decline.

(Thanks to my patient, Jay F. for pointing me to the LA Times article.)

Learn more:

Los Angeles Times article: Diabetes can take six years off your life by increasing risk of cardiovascular disease and cancer, study says

Washington Post article: Study: 50-year-old with diabetes dies 6 yrs sooner

New England Journal of Medicine article: Diabetes Mellitus, Fasting Glucose, and Risk of Cause-Specific Death

Tangential Miscellany

The nice folks at US Airways Magazine reprinted my post Live Long and Prosper in their March issue. So if you’re flying US Airways this month, please grab a copy and persistently badger the passenger next to you about my practice.

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Evidence Mounts in favor of Weight Loss Surgery

Readers who have been following my posts for a few years know that weight-loss surgery is amassing an impressive body of scientific evidence supporting its effectiveness and safety. (Links to my previous posts about weight loss surgery are below.)

This week, two studies in the Archives of Surgery attempted to compare the different kinds of weight loss surgery. An LA Times article (link below) has a clear explanation of the different kinds of surgery and summarizes the findings of the studies. The studies suggest that gastric bypass may be more effective than gastric banding or than sleeve gastrectomy for certain important outcomes. One of the studies randomized moderately obese patients with type 2 diabetes to gastric bypass or sleeve gastrectomy. 93% of the bypass group had their diabetes resolve, compared to 47% of the group that had sleeve surgery. The amazing thing isn’t which surgery was better; the amazing thing is that these patients don’t have diabetes anymore. We don’t have medications that can do that.

I find the accumulation of evidence in favor of weight-loss surgery a fascinating trend because of the comparisons to diet and exercise. Though I constantly recommend diet and exercise to my overweight patients, the long term scientific evidence for it is quite shaky. Most overweight people eventually regain weight after dieting, and long-term success stories are the exception not the rule. I have certainly had motivated patients who have lost weight and kept it off, but large studies suggest that most patients can’t (or don’t). So the counter-intuitive truth is that weight loss surgery is actually a more evidence-based treatment for obesity than diet and exercise.

The other interesting facet about this trend is that obesity is an illness in which surgery is clearly more effective than medications. In many diseases such as heart disease and stomach ulcers surgical treatments are becoming much less common as medications improve. Coronary bypasses will be quite rare in our children’s lifetimes because of the improvements in cholesterol and blood pressure medicines. But for obesity, the medications thus far have been dangerous and ineffective while surgery seems to be providing good results.

So until you discover a safe pill for weight loss, I’ll be recommending surgery for very overweight patients who don’t achieve results with diet and exercise.

Learn more:

LA Times article: Gastric bypass more effective than other procedures, studies find

LA Times graphic: Gastric surgeries compared

Archives of Surgery article: Better Weight Loss, Resolution of Diabetes, and Quality of Life for Laparoscopic Gastric Bypass vs Banding

Archives of Surgery article: Gastric Bypass vs Sleeve Gastrectomy for Type 2 Diabetes Mellitus

My previous posts about weight loss surgery:

Gastric Banding is an Effective Option for Obese Teens

Laparoscopic Gastric Banding Can Cure Diabetes in Obese Patients

Surgery for Weight Loss May Save Lives

Gastric Banding is a Reasonable Treatment Option for Obesity

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This Isn’t Your Father’s Heart Disease

What’s the most common cause of death among American women? Breast cancer? Accidents? Suicide after watching too many Lifetime Channel specials? Nope. Heart attacks kill more women than any other cause—same as men. A generation ago heart disease was mistakenly thought of as an exclusively male disease, but patients and physicians have learned that preventing and treating heart disease is critical in women too.

This week the American Heart Association published their updated recommendations for the prevention of cardiovascular disease in women in their journal Circulation. The good news is that the age-adjusted incidence of heart disease in women has been declining for some time as treatments for diabetes, high blood pressure, and high cholesterol have improved. The bad news is that our aging population and the increasing prevalence of obesity and diabetes suggest a possible increase of women’s heart disease on the horizon.

The updated parts of the recommendations alert physicians to cardiovascular risks that have been previously unappreciated. Complications of pregnancy, including gestational diabetes and preeclampsia, increase the subsequent risk of cardiovascular disease. Autoimmune disease such as lupus and rheumatoid arthritis are also associated with increased cardiovascular risk.

The recommendations also feature an important reminder about interventions that do not prevent heart disease in women. Unfortunately some of these treatments have become so popular through misinformation that a reminder that they don’t prevent stroke or heart attack is useful.

  • Estrogen replacement therapy does not prevent stroke or heart attack.
  • Antioxidant vitamin supplements (vitamin E, C, and beta carotene) do not prevent stroke or heart attack.
  • Folic acid, vitamin B6 and vitamin B12 do not prevent stroke or heart attack.

The most valuable part of the recommendations is not new. These recommendations have been known and stressed for years but they deserve repetition because they are the most effective means of cardiovascular disease prevention. (Follow the link below to the Circulation article if you want much more detail about each recommendation.)

  • Women should avoid smoking.
  • Women should exercise regularly.
  • Women should eat a diet rich in fruits, vegetables and whole grains, eat fish at least twice a week, and limit intake of saturated fat, alcohol and sugar.
  • Women should maintain a normal weight.
  • Women should maintain normal blood pressure through the above lifestyle modifications or through medications.
  • Women should maintain normal cholesterol levels through the above lifestyle modifications or through medications.
  • Women should maintain normal blood sugar levels through the above lifestyle modifications or through medications.

Of course, these same recommendations also apply to men.

Learn more:

Los Angeles Times Booster Shot: New heart health guidelines for women

Bloomberg Businessweek article: Experts Issue New Heart Disease Guidelines for Women

Circulation article: Effectiveness-Based Guidelines for the Prevention of Cardiovascular Disease in Women—2011 Update

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